Eating your marshmallows – Part One: The slippery slope to burnout

The Stanford marshmallow test has always fascinated me. Led by psychologist Walter Mischel at Stanford University in the 1960s, the series of studies looked at a young child’s ability to delay gratification. If they could wait and not eat the marshmallow in front of them until the adult returned, they would be rewarded with a second one. It was found that those who were able to exhibit this type of self-control were more likely to succeed in life [1]. For me, the long road of medical training is like asking you to forgo eating a large number of accumulating marshmallows for a very, very long time. The promise of a future reward is constantly dangled in front of you but it often feels like the obstacles along the way are so great, you’ll never get there. One of the biggest obstacles I faced was surviving the junior hospital years – so here is my story.

I started my medical career working in a highly regarded major tertiary referral hospital, fresh faced and excited to learn. I was looking forward to making new friends and I had a strong desire to put years of study into practice. Like most interns, I quickly began to live and breathe work. Even in my free time, I often spent it with my peers as we mutually celebrated our new financial freedom and working life. I felt like I was part of something, I was part of a team. I always helped the other resident on my ward, making sure I pulled my weight. I became known by the nurses as “the nice one”, always approachable and responsive to any request. Full of empathy and compassion, I willingly spent extra hours at the end of my shift with patients and their families explaining their care. I looked up to my experienced registrars, and diligently accepted my responsibilities. In essence, I was thriving by having a new sense of purpose. I’m not going to lie, there were frequent moments of anxiety due to a high level of self–doubt and fear of making a mistake. However, I managed to bounce back from these moments and was slowly gaining confidence in my skills.

Fast forward to two years later. My morning as a junior doctor began like every other day. I met up with my fellow resident and we prepared for the ward round, taking the opportunity to guzzle some coffee to open our weary eyes. It felt like I hadn’t slept, it felt like ground hog day. I grumbled negatively to my friend “Here we go again”. I didn’t feel like myself anymore. I was increasingly bitter, quick to anger and uncharacteristically bothered by the typical nursing staff requests. I wanted to sneak into the ward unseen, so I could get in and get out, cross off my tasks and go home. When a patient became ill, instead of feeling my usual sense of compassion and duty, I was frustrated. This meant I’d be home late again. I felt bone crushingly exhausted despite a decent nights rest. There was no time for “me” outside of this 80 hour 6-7 day a week job. My family and friends never saw me. I had missed countless weddings, baby showers, and birthday celebrations, and worked almost every public holiday including Christmas, New Years and Easter. The hospital had allocated my five-week block of annual leave, and unfortunately this meant it had been 18 months since I’d had a holiday. “Just keep going, you are almost there” I’d tell myself on a daily basis. I had one week to go but it felt like a lifetime. I had begun to have frequent thoughts of wishing I’d done something else with my life, and felt overwhelmed at the prospect of having to spend another few years doing the same thing, over and over until I had specialised. I found myself feeling envious of others who had 9-5 low-stress jobs. I knew I was struggling, however, many of my peers felt the same way. We were all battlers, in it together, bound by the system, and for many months I had found some comfort in that thought.

At the end of yet another long shift as I was packing up to leave, a nurse asked me to put an intravenous cannula in a patient that wasn’t my responsibility, as their resident had failed to respond to multiple pages. So I paged him myself. After not hearing back, I grumpily agreed to do it this time, as I knew the patient would suffer without it. Forty-five minutes later, after four failed attempts, I found myself in the storeroom furious and frustrated that I was missing another dinner with my friends after taking on a responsibility that wasn’t mine. To top it off, I had failed at a task I thought I had mastered. I stopped caring about the patient. I angrily (and dangerously) threw the needles into the bin, swearing out loud, just as the nurse walked in. Feeling incredibly inadequate, hopeless and overwhelmed, I immediately burst into tears. I’d reached my limit.

So how did I become a person who I barely recognised? Over time the demands placed upon me had taken its toll. I realised I had become a victim of “Doctor Burnout”. It’s a term to describe the physical and emotional changes that occur with chronic unrelieved stress. Burnout and doctor suicide is gaining more and more awareness in the media and so it should. It’s real. Beyond Blue’s National Mental Health Survey in 2013 suggested that almost 50% of younger doctors were experiencing symptoms of burnout [2]. The key triad consists of emotional and physical fatigue, a sense of depersonalisation and cynicism, and a reduced sense of achievement or contribution due to a low professional efficacy [3]. These symptoms develop gradually as you become increasingly unable to recover between insults, and they tend to peak when it begins to affect your quality of life and relationships outside of work [3]. It’s easy to see how this spiral can lead to doctors questioning their career decision and feeling as though they want to quit medicine all together.

There are many burnout risk factors, both at an individual level, and an environmental level. Interestingly, a recent MJA insight article highlighted that while burnout certainly occurs in male doctors, single young female doctors who possess a strong work ethic, and high levels of empathy and self-criticism are most at risk [4]. This combination leads them to take on more than they can emotionally and physically handle [4]. I certainly feel I fit this demographic.

In terms of environmental influences, a key risk factor is a highly demanding job with a low level of autonomy [3]. As junior doctor, on call and extra weekend shifts are routinely rostered, leading to very long working weeks. At all times during your shift there are high expectations on your level of performance and organisation. Often, the list of tasks placed upon you to achieve in a day is impossible. You are expected to run all major decisions by your senior registrar or consultant, yet they are often so overworked themselves that the support system fails. You are subsequently forced to take on responsibilities above your experience level. There are no sheltered morning tea or lunch breaks – it is viewed as a luxury. A “good day” for me was when I managed to make it to the hospital cafe for a cappuccino and a proper lunch instead of surviving on ward snacks at my desk. Clearly this is not the making of a healthy lifestyle.

To survive the onslaught over the first few years, I learnt the skill of leaving work at work, which is difficult when faced with distressing situations and an endless list of chores. Detachment and compartmentalisation requires conscious practice. Another important buffer was the sense of comradery I felt with my fellow junior doctors and the ability to debrief with others who understood my plight. I think that was probably what finally broke me that day – I felt that one of my own teammates let me down.

So the following day, I decided to put aside my work ethic guilt and made an appointment with my GP, who promptly handed me a medical certificate. I instantly felt a burden lift from my shoulders. Relieved, I took what felt like my first breath in months. Over the following week I focused on myself completely. I avoided social media and emails and unnecessary chores. I just rested, read, ate well and made sure I got outside in the sunshine and exercised every day. It was the beginning of my healing.

Although in hindsight I should have sought assistance sooner and prevented burnout taking hold, the silver lining was that I recognised my unhealthy pattern before I made a mistake, quit, suffered significant relationship difficulties or dived head first into a depression spiral. Unfortunately, not everyone is able to avoid such consequences. A lack of self-awareness, lack of perceived control, or a fear of seeking help due to possible workplace repercussions leads some down a very dark lonely path. I was eventually able to push past the guilt that comes with feeling indispensable and put my needs first. So there I was, forcing myself to step outside of life’s pressures to focus on myself again. In this moment, I had paused, and given myself permission to eat one or two of my marshmallows. And although this allowed me to recover in a physical sense, it turned out to be much more than that. It marked the beginning of a change in direction for me, and ultimately led to a major career decision.

About The Author

Leena O’Brien is a General Practitioner from Brisbane with an interest in Women’s and Children’s health. She graduated with a MBBS from the University of Melbourne in 2005 and obtained her General Practice Fellowship in 2011. Since marrying an American in the US Air Force, Leena relocated to Europe initially and is now currently living in the United States. She enjoys working part time in medical education as an Adjunct faculty member of a local US medical school and frequently returns to Australia as a GP locum to maintain her clinical skills. Her passions outside of medicine include skiing, travelling and raising a family.